Charting is time consuming for any nurse, but for the new graduate nurse who is still figuring out their online charting system, it can feel like such a chore! These five tips are here to help you figure out charting, as well as make your time charting more efficient. The following are five charting tips for new nurses!
1. Play with the Charting System in your Preceptorship
Any downtime you might have during your preceptorship is a great time to really learn your charting system. Watch your preceptor chart and see how they use the system. Oftentimes there is more than one way to get to each tab. By learning the system now, you won’t be as confused by it later on.
Also check out How to Get the Most Out of Your Preceptorship for more preceptor tips!
2. Set Aside Charting Time
By planning your shift, you can more easily set aside time to sit down and chart. Sometimes charting will have to be done in a patients’ room while you’re giving blood or trying to reorient a confused patient, but it’s still productive charting time!
Check out my post on How to Organize Your 12-Hour Nursing Shift!
3. Chart One Patient at a Time
When you go to chart on a patient, there is most likely multiple tabs you are required to chart in (such as Assessment, Lines/Drains/Airways, Pain ratings, Patient education, Outcome evaluation note, etc.) and some of these sections require q4 charting. In order to be more efficient with your time, sit down and do one patient at a time.
When you’re first starting out, it might be wise to do your assessment and immediately chart in the patients’ room. This way you can go back and assess anything you might have missed. Then once that patients charting is done, move on to the next one. But once you gain some experience, you’ll soon learn to only mark down any assessment abnormalities and chart on it later to save some time.
Also be sure to visit Nursing Fundamentals: A Guide to Pain and Patient Education: How to Effectively Manage Acute and Chronic Pain for more information.
4. Have a Charting Section on Your Brain
Create boxes on your brain that detail which tabs need to be charted on for which patient. By doing so, you can easily see where you left off if you get called into another patients’ room. Which I’m sure you know happens all the time!
See my Organizational Brain Template for New Nurses to see where I put my charting boxes!
Pro tip: Also on your brain, be sure to write down any assessment abnormalities for each patient so when you go to chart on this you can easily reference your notes.
5. Outcome Evaluation Note
Your note is likely one of the most important charting sections. You’ve probably heard something like, “chart like one day it might be read aloud in court” and boy is this true. Your note should include an overview of any assessment abnormalities, PRN medications you gave, pain assessments, patient goals, and patient education. Be sure to include any patient care details in your note that may not be charted on in another tab.
And that’s all! Be sure to visit the following for more helpful new grad tips!
- 10 Best Amazon Must Haves For New Grad Nurses
- Nursing Bag Essentials for New Nurses
- Adjusting to Night Shift
- Medical Abbreviations You Must Know
- Essentials of a Good Bedside Handoff Report
- Imposter Syndrome as a New Nurse